(1) The requirements and restrictions in this rule apply for purposes of coverage and reimbursement of therapy services under the Montana Medicaid program.

(2) Except as otherwise provided by these rules, therapy services must be provided by a therapist or assistant/aide within the scope of practice permitted by state law. The provider's records maintained under ARM 37.85.414 must demonstrate compliance with applicable supervision and protocol requirements.

(a) Services provided by an assistant/aide may only be billed by a supervising therapist.

(3) Therapy services may be provided to a recipient only upon a current written or verbal order or referral by a physician or mid-level practitioner. All verbal orders or referrals must be followed up by a written order received by the provider within 30 days of the verbal order or referral.

(a) The provider is not entitled to Medicaid reimbursement if services are provided prior to actual receipt of the written or verbal order or referral. Referral and orders are valid for Medicaid purposes for no more than 180 days.

(b) The provider must maintain the referral or order of the physician or mid-level practitioner and appropriate records that demonstrate compliance with Medicaid requirements. The provider must provide copies of these documents at no charge to the department or its agents upon request.

(4) Services that do not require the performance or supervision of a licensed therapist are not reasonable and necessary even if the services are performed by or under the supervision of a licensed therapist.

(5) Maintenance therapy services are not covered or reimbursable under the Montana Medicaid program.

(a) Establishment of a maintenance therapy plan by a licensed therapist is reimbursable. Establishment of a maintenance plan includes the initial evaluation of the recipient's needs, development of a plan that incorporates the treatment objectives of the prescribing physician or mid-level practitioner and that is appropriate for the recipient's capacity and tolerance, instruction of others in carrying out the plan and further evaluations by a licensed therapist as required.

(6) Medicaid reimbursement for therapy service procedures includes all related supplies and items used in the performance of the service, except that the design, fabrication, fitting, and instruction by a licensed therapist in the use of splints, braces, and slings are reimbursable as provided in ARM 37.86.1801 through 37.86.1807.

(7) The following limits apply to therapy services:

(a) Occupational therapy services are limited to 40 hours per state fiscal year per recipient. Individuals age 21 or older are not eligible to receive additional hours over 40.

(b) Speech therapy services are limited to 40 hours of service per state fiscal year per recipient. Individuals age 21 or older are not eligible to receive additional hours over 40.

(i) One unit is equal to one visit code or four 15-minute increment codes as provided in the CPT.

(c) Physical therapy services are limited to 40 hours of service per state fiscal year per recipient. Individuals age 21 or older are not eligible to receive additional hours over 40.